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Monday, June 11, 2012

Alzheimer's and Anesthesia


Alzheimer's and anesthesia don't mix well. Some physicians are advising their patients that are already diagnosed with Alzheimer’s to avoid surgery unless absolutely necessary.

By Sydney S. Farrier, LCSW

Alzheimer's and Anesthesia
Sydney S. Farrier
How often have you heard the comment about an older person who recently underwent a major surgery, "She was fine until she had that (hip surgery, knee replacement, cardiac surgery, etc) but now she seems confused."

This week I was visiting with an attractive woman in her 80's who had a knee surgery under a general anesthesia a couple of years ago. About six months after the first surgery, another surgery with general anesthesia had to be done due to some problems with the knee. She stated she has never recovered.

Her knee is fine, but the cognitive problems she experienced following these surgeries has resulted in her having to give up her home and the gardening she loved, move to a retirement community near her daughter, forgo driving, and lose the sense of independence she so valued.

Both she and her daughter believe the two general anesthesia significantly contributed to her cognitive changes. She is angry that the possibility for cognitive changes was never discussed with her.

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Scientists recognize that there is normal brain aging. Age related neuronal loss does take place, but the most recent research indicates that the older brain can make new neurons even into late old age. There is also evidence that physical exercise and intellectual exercise and activity improve cognitive functioning. However, the older brain may be less resilient and more susceptible to long lasting cognitive changes due to anesthesia.

A report from researchers from Massachusetts General Hospital indicates that research with mice given an anesthetic commonly used in surgeries found "changes to their brains similar to the damage found in Alzheimer's disease."

In Alzheimer's disease amyloid-beta protein clusters called plaques build up in the brain. Dr. Alois Alzheimer first identified these plaques and tangles in the brain of a patient at autopsy in 1804. Changes to the brain often occur before symptoms are present.

Knowing that older people in particular are at risk for experiencing cognitive problems after anesthesia, Dr. Zhongcong Xie at Mass General Institute for Neurodegenerative Disease gave mice doses of isoflurane for two hours and then compared them to mice that did not receive the anesthetic.
"After six hours, there were signs that programmed cell death was beginning and levels of an enzyme that makes amyloid-beta protein were rising in the brains of mice that were given isoflurane. After 24 hours, the enzyme was four times higher in mice who had received isoflurane than in untreated mice, supporting the idea that the anesthetic not only triggers cell death but also spurs excessive production of amyloid-beta protein."
Dr. Roderic Eckenhoff, an anesthesiologist and researcher at the University of Pennsylvania, states, “We give these drugs to tens of millions of patients every year, and blithely ignore that they could have long-term effects.”

Researchers explain that, with scarce clinical data, it is premature to change operating room procedures, but some physicians are advising their patients that are already diagnosed with Alzheimer’s to avoid surgery unless absolutely necessary.

Others, like Dr. Rudy Tanzi, of Mass General in Boston, are selective about which inhaled anesthesia is used when surgery is unavoidable. When his mother required a surgery, he requested that the anesthesiologist use desflurane rather than isoflurane. He reports that his mother woke from surgery clear headed and without the fuzziness and confusion that she had experienced for several days following previous surgeries.

Isoflurane is an inhaled general anesthetic that is often used in cardiac bypass surgery.

A January 2007 article in Biochemistry included an article from the University of Pittsburgh School of Medicine that indicated that inhaled anesthetics are more likely to cause a clumping of plaque than intravenous anesthetics. Inhaled anesthetics of halothane and isoflurane appeared to have the "most potent interaction with amyloid-beta peptides and aggregation.

Sevoflurane is another inhaled anesthetic that can be avoided. Injected anesthetic propofol showed this result only at high concentrations. More research is required and research with human trials needs to take place.

But for now, if you are a senior (as defined by eligibility for any "senior discount") and you require surgery, please protect your brain.

If you must undergo a surgery, have a serious and frank conversation with your surgeon and the anesthesiologist about the type of anesthesia to be used, the possible effects on your brain, and what alternatives are available. (Many physicians do are not aware of the research.)

Also, exercise, eat a heart healthy diet, and stay socially and mentally engaged.

1 White Coat Notes, "Experiments in mice link common anesthetic to Alzheimer's-like brain changes.
Elizabeth Cooney, November 12, 2008
2 White Coat Notes, Elizabeth Cooney, November 12, 2008
3 Dance, Amber. “Inhaling Alzheimer’s? Hazy Picture Links Anesthesia, AD” Alzheimer’s Research Forum 2009. http://www.alzforum.org/. cited 6/2012
4 University of Pittsburg Medical Center. “Role of Anesthetics in Alzheimer’s Disease: Molecular Details Revealed.” January 25, 2007

Sydney S. Farrier is a Licensed Clinical Social Worker with over 40 years of experience working with adults and children. Sydney has held positions of Director of Social Work and Executive Director in nursing facilities and an Alzheimer’s Assisted Living facility in the Dallas area, worked for the Dallas Chapter of the Alzheimer's Association, developing and implementing the “Trailblazer” program which provides education and support to those with early stage and young on-set Alzheimer’s disease and related dementia. She is currently at partner in DFW Aging Solutions, LLC, a company that provides continuing education for professionals in the field of health care and Alzheimer’s care.

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